Social determinants of mental health influencing the emergency department experiences of Latinx children and adolescents with mental and behavioral health crisis and their care partners: An interpreta

Traditional guidance for preoperative pediatric fasting has recommended at least 6 h for solids or non-human milk, 4 h for breast milk, and 2 h for clear liquids (the 6-4-2 rule), with the aim of reducing the risk of pulmonary aspiration of gastric contents under anesthesia. The 2-h clear-liquid rule has increasingly been challenged on practical, physiological, and psychological grounds. Gastric-emptying studies using ultrasound and magnetic resonance imaging demonstrate that water is reliably cleared from the stomach within approximately 30 min [], and several national anesthesia societies have shortened their recommended clear-fluid fasting interval from 2 h to 1 h [–]. Some institutions have gone further, permitting clear liquids until the time of surgery (a 0-h policy) []. Reported experience with these more liberal policies, however, comes largely from observational and quality-improvement work, and direct comparisons of 1-h and 0-h approaches remain sparse. In practice, children frequently fast far longer than guidelines intend, with average clear-liquid fasting times of 6–9 h and fewer than 20% of children achieving less than 4 h [, ]. Caregiver reluctance to give fluids for fear of cancellation, unpredictable theatre scheduling, and emergency cases all contribute to prolonged fasting. Prolonged fasting carries measurable consequences: in a study of approximately 15,000 patients, those who fasted 4 h or more had a 30% higher risk of hypotension after induction than those who fasted less than 4 h []; prolonged fasting is also associated with increased insulin resistance, ketogenesis, and hypoglycemia [], and children report substantial hunger and thirst []. Quality-improvement programs that shortened clear-fluid fasting from 2 h to 1 h have reduced prolonged fasting by more than 50% [, ], and liberalized policies have been associated with shorter fasting times and improved patient well-being without a detected increase in aspiration [–]. Despite this growing evidence, adoption of unrestricted clear-fluid protocols remains variable, and few data describe their implementation in low-resource settings. AIC Kijabe Hospital is a tertiary mission hospital in rural Kenya that cares for approximately 2,000 pediatric surgical patients annually, where stakeholders suspected that preoperative fasting times were prolonged. This study describes the impact of a phased reduction in clear-liquid fasting restrictions on fasting time, patient and caregiver experience, and observed safety events. We hypothesized that progressively liberalizing the clear-liquid fasting policy would substantially reduce fasting time and improve the perioperative experience, without an observed increase in clinically significant aspiration events.